Comprehensive School Health Model: An Integrated

School Health Education and Physical Education Program

Mohammad R. Torabi
Department of Applied Health Science
Indiana University-Bloomington, U.S.A.

Jing-Zhen Yang
Department of Health Behavior and Health Education
University of North Carolina-Chapel Hill, U.S.A.

Abstract
The importance of school health education in promoting the health of young people and
contributing to the overall public health has been recognized worldwide. With the
development of China’s public and school health education, the demand for professionals
involved in the design, implementation, and evaluation of effective school health
programs is inevitably increasing.

This presentation intends to introduce contemporary school health programs in the

United States, in general, and discuss a conceptual framework developed for China’s
school health program, in particular. Currently, two models are widely adopted in the
United States in guiding its school health programs -- the Comprehensive School Health
Program (CSHP) and the School Health Coordinator (SHC). Special attention will be
directed for delivering these program elements in a coordinated and interactive manner
and how to integrate physical education and health education in a comprehensive health
program for schools. The constructs in current China’s school health programs will be
identified. A conceptual framework that may be of assistance in China will be defined by
combining the theories of behavioral science and the practices of China’s education
system and school health programs. Health education and physical education, as well as
how these two elements could be best integrated to motivate the efforts of schools,
families, and communities in health promotion, will be emphasized in the conceptual
framework. Further study is needed to provide empirical evidence for effectiveness and
acceptability of our proposed model for the Chinese culture. The information provided
might be helpful in the current development of physical education embedded in public
health, in general, and school health in specific.

INTRODUCTION
Ever since human beings have lived, health has been a great concern of nearly every
individual, community, society, and country. The battle to achieve optimal health for
everyone has never ceased. During the last century, dramatic strides have been made in the
health field. In the United States alone, health status has been greatly improved in the
following aspects: prolonged life expectancy, declining mortality rate, declining infant
mortality, and advanced modern biomedicine (Barsky, 1988). Nevertheless, the United

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States is still facing great challenges in the battle of health for everyone. On one side, the
overall health status of the population is improving, while on the other, the nation each
year is spending more money than ever on its health care. Medical care is playing an
increasing role in daily lives, and yet certain diseases still find ways to spread.

Health education is a profession that stands in the forefront of this centuries old battlefield.
Its role has never been so heightened as today. The goal of health education is to provide
the individual with the information, skill, and motivation necessary to make intelligent
decisions concerning lifestyle and personal health behavior. In any case, health education
is working to promote health, prevent disease, disability, and premature death. Within its
limited space, this paper intends to analyze the trends, challenges, and opportunities health
education faces, to discuss behavioral factors that influence one's health, to introduce the
concept of school health education programs, and to suggest a comprehensive school
health model that might work in China.

Trends, Challenges and Opportunities

Many of the health challenges facing young people today are different from those plaguing
the public’s health a century ago. In the early 1900s, the major causes of morbidity and
mortality were infectious diseases. Many major health threats were diseases associated
with poor hygiene, poor sanitation, poor nutrition, or poor maternal and infant health
(Centers for Disease Control [CDC], 1999a; CDC, 1999b; CDC, 1999c). However,
advances in medications and vaccines have largely addressed the ravages once wrought on
children by infectious diseases. Modern biomedicine has enhanced our ability to predict,
detect, diagnose, and treat the array of diseases to which human beings are heir (Barsky,
1988). During the 20th century, the health and life expectancy of persons residing in the
United States improved dramatically. Deaths from infectious diseases have declined
markedly in the United States (Figure 1). This decline contributed to a sharp drop in infant
and child mortality. In 1990, 30.4% of all deaths occurred among children aged less than 5
years, while in 1997, this percentage was only 1.4%. The decline was also due to more
than 30 years increase in average lifespan of persons in the United States, of which 25
years of this gain are attributable to advances in public health (Bunker, Frazier, &
Mosteller, 1994). Today, the major health problems are caused, in large part, by behaviors
established during youth (Kolbe, 1993). The 10 leading causes of death in 1900 and 1997
(Figure 2) revealed that in 1900, the three leading causes of death were pneumonia,
tuberculosis (TB), and diarrhea and enteritis. In 1997, heart disease and cancer accounted
for 54.7% of all deaths and most of the leading causes of death are health-compromising
behaviors (CDC, 1999a).

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Figure 1:

In comparing Table 1 and Figure 2, the two most rapid growth behavioral causes of death
are sexual behavior and drug use (Table 1) (McGinnis & Foege, 1993). Transmission of
AIDS, which joined the list of top ten causes of death, is attributed mostly to sexual
behavior and drug use. Given that behaviors are often the actual causes of death, a
reduction in the number of deaths caused by many diseases lies not in finding cures for
them but in changing the behaviors that lead to them in the first place. The truth is that the
health of young people, and the adults they will become, is critically linked to the health-
related behaviors they choose to adopt.

Table 1: Nine Leading Behavioral Causes of Death

1 Tobacco
2 Diet and activity patterns
3 Alcohol
4 Microbial agents
5 Toxic agents
6 Sexual behavior
7 Firearms
8 Motor vehicles
9 Drug use
Source: Adapted from McGinnis, J. M., & Foege, W. H. (1993). Actual Cause of Death in the United States.
Journal of the American Medical Association, 270(18), 2207-2212.

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Figure 2:

In the United States, a saying states, “An ounce of prevention is worth a pound of cure,”
which indicates prevention is more important than treatment in general. In many countries
and cultures it is common sense to believe that taking measures to prevent illness can help
more people than the treatment of preventable illness. A lot of people often neglect to
maintain their health when they are young. Consequently, many preventable health
problems are not prevented. This is especially true with most chronic diseases that have
been traced as a result of various unhealthy behaviors. One example of this is the
relationship between smoking and lung cancer.

Prevention is also a cost effective strategy in health promotion and disease prevention.
Researchers in the field have provided sufficient evidence to prove that prevention is most
cost effective in maintaining people's health, reducing morbidity and mortality rates,
saving medical cost, yielding a higher level of productivity, and securing a happier life for
the people in a community or society. Existing data have shown that as many as 50% to
80% of deaths caused by cardiovascular disease, strokes, and cancer could be avoided or
delayed by preventive measures. Eliminating smoking could prevent more than 300,000
deaths each year while changes in diet could prevent 35% of unnecessary deaths from
heart disease (Hales, 1999). No amount of money could possibly compensate for those
lives, nor buy people’s health.

Health knowledge is the accumulation of factual information that influences decision

making regarding one’s health. High-quality health knowledge could lead to high-quality
health decision-making. Low-quality health knowledge, alternatively, may create the
potential for health-compromising decisions. When a person becomes more
knowledgeable about his/her own health and about the health of others, and more
competent in the application of that health knowledge, he/she will realize that a positive
healthy life style offers the best prospect for a healthy, long, happy, and productive life.

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However, having knowledge about prevention does not guarantee that a person will
establish a positive attitude toward disease prevention, or practice a healthy behavior as
most positive health behaviors are a matter of voluntary action. People choose them, and
they cannot be forced to accept. Altering one's attitude and behavior often requires special
efforts involving education, manpower, sound strategies, and ultimately, time. Education
that aims at one's behavior change cannot be a onetime snapshot. One school class session,
one community health education program, or once a year mass activity may only yield a
brief, or limited effect.

Schools have the potential to improve the health of young people by providing instruction,
programs, and services that promote a healthy lifestyle for students. Schools are an
efficient vehicle for providing health instruction and programs because they reach most
children and adolescents. In the United States, every single school day, about 52 million
students attend more than 100,000 schools, and roughly 14 million attend colleges and/or
universities (Hales, 1999). In the lexicon of public health and medicine, this means that
schools could prevent many health problems from occurring; detect health problems that
do occur during the early stages when they are most treatable; and treat those problems
that have not been or cannot be prevented, to preclude adverse effects on health and
education (Kolbe, 1993). In short, schools can make an enormous, positive impact on the
health of young people.

The good news for school health education is that health education is now recognized as
being important because it is one of few curriculum areas that emphasize the individual
instead of the subject matter or academic skills. The health information and skills students
learn are not prerequisites for another course, but are immediately applicable to life
(Lohrmann, Gold, & Jubb, 1987). Armed with advanced technology, information super-
highway, health education in today's schools has many advantages it never had before.
Distance learning, internet courses, interactive educational web pages, and the dramatic
increase of computer availability and on-line time add fresh life to school education, which
makes schooling more attractive and effective, learning more delightful and efficient, and
information more broad and accessible. The technology also enables health education to
reach a wider population. School health education is no longer just a classroom lecture or
physical education. Comprehensive school health education programs have been well
recognized and delivered to a majority of campuses nationwide. These programs tend to be
more informative, student centered, demonstrative in scope, sequence, progression and
continuity. Many are designed to develop students’ critical thinking and individual
responsibility for one’s health, structured to incorporate current and emerging health
problems, focused on the dynamic relationship among physical, mental, emotional, social,
spiritual, and environmental well-being, and strengthened by integrating available
community resources into classroom teaching (Collins et al., 1995). Although school
health education curriculums vary from school to school, more community and family
involvement has been included and supported. Cooperation and collaboration among
health educators at local, state, national, and international levels have also fostered the
effectiveness of current school health programs.

Behavior Factors and Behavior Relations

Many external factors can and often affect people’s lives --- from the weather, which can
temporarily dampen or brighten people’s mood, to genetic predispositions that can result in
certain health conditions. Behaviors that affect people’s health include exercising regularly,

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eating a balanced, nutritious diet, seeking care for symptoms, and taking necessary steps to
overcome illness, and restore well being.

Factors that shape positive behaviors include predisposing, enabling, and reinforcing
factors (Hales, 1999). Predisposing factors include knowledge, attitudes, beliefs, values,
and perceptions. Unfortunately, knowledge is not enough to cause most people to change
their behaviors. For example, people who are fully aware of the grim consequences of
smoking often continue to puff away. Nor is attitude --- one’s likes or dislikes --- sufficient;
an individual may dislike the smell and taste of cigarettes but continue to smoke regardless.
Beliefs are more powerful than knowledge and attitudes. Researchers reported that people
are most likely to change behavior if they hold three beliefs, susceptibility --- they
acknowledge that they are at risk for the negative consequences of their behavior; severity-
-- they believe that they may pay a very high price if they don’t make a change; and
benefits --- they believe that the proposed change will be advantageous to their health. The
value and perception also play major roles in changing one’s behavior. Many people aren’t
concerned about their health just for the sake of being healthy. Usually they want to look
or feel better, and be more productive or competitive. Perceptions are the way people see
things from their unique perspective and they vary greatly with age.

Enabling factors include skills, resources, accessible facilities, and physical and mental
capacities. Before a person initiates a change, he/she needs to assess the means available to
reach his/her goal. No matter how motivated a person is, he/she will become frustrated if
always encountering obstacles.

Reinforcing factors may be praise from family and friends, rewards from teachers or
parents, or encouragement and recognition for meeting a goal. Although these factors help
a great deal in the short run, lasting change depends not on external rewards, but on an
internal commitment and sense of achievement. To make a difference, reinforcement must
come from within. A decision to change a behavior should stem from a permanent,
personal goal, not from the desire to please or impress someone else.

Several studies demonstrated that when people took health-related actions, positive or
negative, the next health-related action followed suit. One positive action taken would
likely lead to another positive action, while a negative health related action would beget a
negative action. For example, if an individual always wears a seat belt when he/she is in a
car, he/she is more likely to wear a helmet when biking. This is because he/she has
established a momentum for safe habits on the road. A study (Torabi et al., 1991) found
that there was a statistically significant relationship between involvement in any varsity
sport and smoking cigarettes (Table 2). Students who were active in varsity sports were
less likely to smoke cigarettes as compared to those who were not involved. The finding
indicated that varsity functions might discourage the use of cigarettes.

Table 2: Distribution of Students by Sports Participation and Cigarette Smoking

“Do you take part in any varsity sports?”

Yes No
Yes 253 1035
“Do you smoke cigarettes?”
No 2234 4497
Chi-square=444.88 (p<0.01)
Source: Torabi et al. (1991).

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The opposite is also true, one bad habit can lead to another. The “gateway drug effect”
explains that. The gateway drugs are the drugs that serve as the “gate” or path to the use
of other drugs. These gateway drugs serve as social and psychological precursors to the
use of other drugs. The decisions to use tobacco or other gateway drugs could set up
patterns of behavior that make it easier for a user to go on to the other drugs which often
leads to adoption of the drug-using lifestyle. Social psychologists refer to this phenomenon
as a “developmental progression”. Children who decide to accept the risks of smoking
later find it much easier to accept the risks of using other drugs.

The study conducted in Indiana by Torabi, Bailey, and Majd Jabbari (1993) through the
Indiana Prevention Resource Center at Indiana University found a dose-dependent
relationship between an increasing level of cigarette smoking and an increased frequency
of binge drinking. The results showed a powerful relationship between heavy smoking and
heavy drinking (Table 3). The study also examined the relationship of reported smoking
behavior with use of alcohol and other drugs (Table 4), which revealed that smokers were
much more likely than nonsmokers to use all drugs listed. The likelihood of using other
drugs was increased, along with the frequency of cigarette smoking. These results are
consistent with the results reported by the National Center for Health Statistics (NCHS).

Smokers tend to have other bad habits. A nationwide survey also showed that heavy
smokers compared to nonsmokers were more likely to skip breakfast, snack more during
the day, drink more alcohol, and remain physically less active. Two factors that might play
an important role need noting. One is that this cluster of bad habits is associated with a
consumption-oriented lifestyle --- smoking, drinking, and overeating. The other is that
smokers are more prone to risk taking behaviors and give less attention to healthier
practices (Pruitt & Stein, 1999) (Table 5).

Table 3: Dose-Responses Relationship Between Cigarette Smoking and Binge Drinking in

Indiana Students in Grades 5-12 Percent of Students in Each Smoking Category
Reporting Binge Drinking

Rate of Cigarette Smoking Reported in Past Year

1-5 cigs. 1/2 pk 1 pk 1 1/2 pk 2+ pk
None Few Times
day day day day day
None 92.7 67.8 53.4 40.8 34.5 24.2 27.7
Once 3.8 14 17 17.1 14 10.8 6.9
Twice 1.6 7.8 11.2 12.8 14.2 18.3 11.3
3-5 Times 1.2 7 11.6 17.5 17.9 22.6 7.5
6-9 Times 0.3 1.6 3.7 7.1 9.5 10.8 7.5
10+ Times 0.4 1.7 3.2 4.7 9.8 13.4 39

Chi Square = 5895.44. p<0.01

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Table 4: Dose-Responses Relationship of Cigarette Smoking with Alcohol and Other Drug
Use by Indiana Students in Grades 5-12 Percent of Students in Each Category of
Smoking who Report Use of Named Drug at Least Once in the Past Year

Rate of Cigarette Smoking Reported in Past Year

Few 1-5 cigs. 1/2 pk 1+ pk
None
Times day day day
Alcohol* 34.5 80.2 87.6 92.9 93.8
Smokeless Tobacco* 7.5 35.1 44.2 47.6 57.6
Marijuana* 1.5 12.9 33.3 54.6 68.2
Cocaine* 0.3 1.3 3.4 8.3 23.8
Crack* 0.2 1.1 2.1 4.4 16.2
Inhalants* 3.6 12.7 20.6 24.7 36.7
Amphetamines* 1.5 11.2 24.4 37.4 51.1
Tranquilizers* 2.8 10.7 20.6 28.3 42.5
Prescription Narcotics* 1.5 4.2 9.9 16 33.2
Psychedelics* 0.7 3.8 9.3 19.2 37.2
Heroin* 0.2 0.6 2.5 3.5 16.6
Steroids* 0.8 2.3 4.1 6.4 16.1
*Statistically significant at p <0.01

Table 5: Smoking Habits and Health Practices

Health Practice Never (%) Former (%) Current (%)

Never eats breakfast 18.3 19.0 37.6
Heavy drinker* 7.2 11.9 20.1
Sleeps 6 hours or less 20.9 20.0 25.3
Less physically active 17.3 18.1 21.8
Note: * indicates at least 5 drinkers on 10 days or more in the past year.
Source: Pruitt & Stein. (1999).

EVOLUTION OF SCHOOL HEALTH PROGRAM

Health education has an ancient and complex history. Its beginnings can be located within
the very foundation of civilization. Much of the early history of the profession closely
parallels that of medicine and its associated sciences. In later time, particularly since 1800,
the history of health education has taken on a richness and character uniquely its own.

History of school health education can be dated back to period of recognition (1850-1880)
when people start to recognize that school could be used to educate/screen for disease and
solve health problems. From 1880 to 1920, school health education experienced a period
of exploration when children’s health problems were emphasized and funded studies were
done to document these health problems. In 1910, the American Physical Education was

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renamed American School Hygiene and Physical Education. In 1927, the American School
Health Association was founded. Since the 1980s, more sophisticated school health
education programs were developed, which brought school health education into a new era.
The growing researchers in school health education demonstrated that school health
education offers students not only the opportunity for improved health status, but also the
opportunity to achieve a life-style that would lead to a satisfying and productive life
(Porter, 1987).

Historical School Health Model

From the late 1880s until the late 1990s, school health programs were conceived as having
three components: health education, health services, and healthy school environment
(Figure 3), which still serve as a base for the school health education program today.

Figure 3: Historical School Health Model

Comprehensive School Health Program (CSHP)

During the 1980s, more sophisticated conceptions of the school health program were
proposed. In 1987, Allensworth and Kolbe (1987) proposed a model, the Comprehensive
School Health Program (CSHP), which extended the classic triad of health education,
health services, and healthy school environment to include physical education, counseling
and psychological services, nutrition services, health promotion for staff, and
parent/community involvement interactive components. This model (Figure 4), broadly
adopted in the United States and internationally, is an organized set of policies, procedures
and activities designed to protect and promote the health, safety, and well-being of
students and school staff (Meek, Heit, & Page, 1996).

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Figure 4: Comprehensive School Health Program

The CSHP model requires systematic coordination among eight components to magnify
the benefits available in each component. In general, schools by themselves cannot, and
should not be expected to address a nation’s most serious health and social problems.
Collaborative efforts among families, health care workers, the media, religious
organizations, and community organizations must be involved to maintain the well being
of young people. The glue that could cement each component is health education, for it is
the major source of the one element common to all components --- health knowledge.

School Health Coordinator (SHC)

Although professionals acknowledge that the eight program elements of the CSHP should
be delivered in a coordinated, interactive manner, numerous issues regarding how this
integration can be achieved --- including who at the school level should accept this
responsibility and how the eight components relate to each other conceptually and
logistically, have not been adequately addressed (Resnicow & Allensworth, 1996).

In essence, CSHP transforms several solo performers into an orchestra. Extending this
metaphor, CSHP assumes that the aggregate of a synchronized, integrated school health
program will produce a product greater than the sum total of its parts. Therefore, the actual
success of CSHP hinges largely on a coordinating mechanism. However, the role of a
coordinator within the eight component model has not been articulated adequately.

In 1996, Resnicow and Allensworth (1996) proposed a model -- the School Health
Coordinator (SHC, see Figure 5), which is revised from CSHP. The main feature of SHC
is that it set up the school health coordinator component, an essential and unifying element,
into the model. The major function of the SHC component is the coordination. Its principal
responsibilities include administration, integration of personnel and programs, evaluation,

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and direct intervention. The direct intervention includes coordinating three program
elements --- health promotion for staff, healthy school environment, and parent/community
involvement. Therefore these three components are considered as “second strings” which
are assigned to the school health coordinator component to support and enhance the impact
of the other five core elements remaining in the CSHP model. Folding these three elements
into the role of the coordinator effectively reduces the number of program elements from
eight to five, or six if the coordinator is considered an additional element, and thereby
minimizes the number of elements which schools must adopt (Resnicow & Allensworth,
1996).

Figure 5: School Health Coordinator

In the SHC model, two committees are created to assist in implementing local
comprehensive school health programs, the School Health Committee and the Community
School Health Coordinating Council. The former comprises personnel representing five of
the eight CSHP components including representatives from health education, physical
education, nutrition services, counseling/psychology services, and health services. The
primary functions of this committee are program planning and advocacy. With regard to
program planning, the committee will ensure that the various professionals who directly
influence student health, convene regularly to learn what their colleagues are doing, share
teaching strategies, problem solve, and plan synergistic activities such as a coordinated
classroom nutrition education and food services campaign. The committee also will
contribute to curriculum selection and adaptation, as well as planning and designing in-
service training programs. With regard to advocacy, this group can serve as a unified front
to help ensure, on the school and district levels, that sufficient resources are allocated to
the health program and when necessary, intervene when individuals or groups within or
outside the school seek to eliminate or unfavorably alter the school health program.

The School Health Coordinating Council extends beyond the school and engages parents
as well as representatives from the local business, media, political, religious, juvenile
justice, and medical communities. The Coordinating Council ensures community support

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for the program, serves as a buffer against threats to local programs by vocal minorities,
provides resource in the form of financial support and donated services, and links school-
based activities to the community.

A SUGGESTED COMPREHENSIVE SCHOOL HEALTH MODEL

FOR CHINA
Health Education became a required subject in primary and secondary schools in China in
1993. However, little has been reported since that time regarding the general status of
school health education in China. The study conducted by Li and colleagues (2000)
regarding current professional preparation of health education teachers and how health
education has been taught in Chinese public schools indicated that 17 of 18 surveyed
provinces provide formal health education among their middle schools. Among the 17
provinces, ten use a national curriculum while the remaining seven develop their own
curricula. Nearly one third (30%) of the schools offer a one-hour health education class
every week, and 60% have the class meet one hour every two weeks. It was found that
current full-time health education teachers have a variety of educational backgrounds and
are not likely to have had professional preparation in health education. Most have a
Biology diploma (33.3%), followed by Medicine (30.3%), Physical Education (15.2%),
and Health Education (15.2%). The study indicated that with the development of China’s
public and school health education, the demand for professionals involved in the design,
implementation, and evaluation of effective school health programs is inevitably
increasing. To have a comprehensive school health program, with sophisticated curriculum,
qualified health educators are needed to promote school health in China and facilitate
Chinese students’ health-related knowledge, attitudes, and practices and to have an impact
upon their daily lives.

The following Comprehensive School Health Education Model (Figure 6), modified based
on existing school health education models implemented in the United States (Allensworth
& Kolbe, 1987; Resnicow & Allensworth, 1996) and the practices of China’s education
system and school health programs. Six components are included in this suggested model.
They are school health education, school physical education, nutrition services, health
clinics, healthy school environment, and parent/community involvement. An overview of
the contents, constructs, and qualifications of each component follows.

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Figure 6: Suggested Comprehensive School Health Model

Health Education
School health education is a planned, and sequential health instruction for grades 1 through
12, which addresses the physical, mental, emotional, social, spiritual, and environmental
dimensions of health. It integrates education as a range of categorical health problems and
issues at developmentally appropriate ages. The school health education curriculum should
focus on not only improving students’ knowledge, but also emphasizing the development
of appropriate skills and positive attitudes toward health and healthy lifestyles (Koble,
Kann, & Collins, 1995). The school health education curriculum should give more
emphasis on the following content areas:

Personal hygiene
Prevention and control of diseases (infectious and chronic)
Injury prevention and safety
Nutrition
Tobacco prevention
Relationships, sexuality and family planning
Physically active lifestyles
Mental and emotional health
Environmental health
Positive attitudes toward meaningful life and living
The school health education curriculum should have the flexibility to incorporate local or
regional health problems as needed.

Health instruction should be implemented by qualified, academically trained teachers and

certified health educators. In order to be effective, schools should only hire those
instructors having proper credentials in the field or at least having a minor consisting of 50

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credit hours in health education. To have a dynamic curriculum, it is important to have the
programs evaluated by regional government and school administrators so that it could be
routinely revised and improved.

Physical Education
School physical education is a planned, sequential grades 1 through 12 curriculum which
provides cognitive content and learning experiences in a variety of activity areas such as
basic movement skills, physical fitness, rhythms and dance, games, team, dual, and
individual sports, tumbling and gymnastics, and aquatics. School physical education
should promote, through a variety of planned physical activities, each student's optimum
physical, mental, emotional, and social development. School physical education should
also promote enjoyable, lifelong physical activity and improve the physical and social
environments that encourage and enable physical activity (Pate et al., 1995; CDC, 1997).
Schools may develop extracurricular physical activity programs that meet the needs and
interests of students and involvement of parents and guardians in physical activity
instruction and programs for young people (CDC, 1997). Schools should hire qualified,
trained teachers to teach physical education. Schools need to have a regular evaluation of
physical activity instruction, programs, and facilities.

Nutrition Services
Cooperating with health educators, the nutrition staff serving the school should take the
opportunity to promote a healthy diet among students. The ultimate purpose of nutrition
services is to promote health by emphasizing a balanced and adequate eating habit.
Nutrition services should provide student access to a variety of nutritious and appealing
meals that accommodate the health and nutrition needs of all students. School nutrition
programs will reflect the Chinese Dietary Guidelines for students to achieve nutrition
integrity. The school nutrition services need to offer students a learning laboratory for
classroom nutrition and health education, and serve as a resource for linkages with family.
Nutrition staff should serve as role models and promote personal hygiene for students. The
director of school nutrition services should have educational and professional experiences
in nutrition and dietary programs. The director should also routinely provide educational
programs for the nutrition services division.

Health Clinic
No comprehensive school health program could be complete without a health clinic.
School health clinics should be staffed by qualified professionals including physicians,
nurses, dentists, health educators and pharmacists. These health professionals should have
experience and expertise in the areas of school health and school aged children. The
purpose of having the health clinic is to appraise, protect, and promote student health.
These services should ensure access and/or referral to health care services. It should also
focus on prevention and controlling communicable diseases as well as emergency care for
illness or injury. The responsibilities of the health clinic include cooperation with other
school staff in promoting a sanitary and safe school environment for students. The health
clinic staff has an important responsibility in the use of the facility for patient education
and student counseling to promote and maintain individual, family, and community health.

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Healthy School Environment

A healthy school environment includes the physical surroundings, psychosocial climate,
and culture of the school. School environment has a significant impact on the health and
well being of school age children. Additionally, the school environment influences the
success of the curriculum on children’s cognitive development. Schools should provide a
physical environment free from biological or chemical agents that are detrimental to health.
School administrators should provide and promote a positive and healthy environment
where students feel safe and happy. Schools should encourage school staff to pursue a
healthy lifestyle that contributes to the school's overall coordinated health programs and
create positive role modeling for students.

Parent/Community/Staff Involvement
School health programs could not be fully implemented without having staff and parents’
cooperation and involvement. Parents, community leaders and teachers often can and do
serve as role models for students. Students serve as a linkage with school and family while
parents can and should cooperate with schools to help their children. The school health
program could impact parents’ knowledge, attitudes and practice regarding healthy
lifestyles. Through newsletters, correspondences, meetings and volunteering, schools and
parents cooperatively, and collaboratively can and should significantly impact the health
and well being of students.

Six components in the Comprehensive School Health Model should reflect six aspects of a
contemporary school health program in China. Coordination of these six components
could have complementary, if not synergistic, effects. All six components need to “work”
together as a whole to address a health behavior or health problem, though each of the six
components has its own content, constructs and qualifications in the field. Further study is
needed to provide empirical evidence for effectiveness and acceptability of this suggested
model.

SUMMARY AND CONCLUSION

Professionals in the health education field believe in the power of education and its
potential impact on one's health behavior choices. While major leading causes of death are
widely linked to unhealthy behaviors, health professionals see the promise through
prevention. However, they don't look at the promise through rose colored glasses. On the
contrary, they do recognize the coexistence of challenges and opportunities.

Unhealthy behaviors of adults are usually sewn during their childhood. Since the greatest
majority of children go to school, there is no place better than schools to provide health
knowledge and skills. For decades in the United States, school health education has been a
major part of the educational force in promoting healthy lifestyles. School health education
has advanced from providing pure classroom lectures of anatomy and physiology to
implementing comprehensive school health programs. Researchers have shown that the
most effective school health education programs are those following comprehensive
school health program models, theory informed, sequentially designed from kindergarten
to the 12th grade, and with family and community involvement.

ICPE 2000 Proceedings 103

 Mohammad R. Torabi and Jing-Zhen Yang

The successful development and implementation of comprehensive school health programs

and health education theories and models in the USA provide a sample profile for health
education in China. The experiences that American health educators have accumulated
over time, as well as the lessons they learned from their practices and research, could be an
invaluable resource to Chinese health educators. This paper suggested a comprehensive
school health model, which functions under the assumption that it might work in the
Chinese system. Further study is needed to provide empirical evidence for effectiveness
and acceptability of this suggested model. It would be of great interest to health educators
on both sides to see how this model works in China as similar models work in the United
States. With health becoming a global concern, why not have health education be global in
task and effort?

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